Theories of Everything with Curt Jaimungal - Addiction, Trauma, Porn, Dopamine Detox | Anna Lembke

Episode Date: November 6, 2023

YouTube Link: https://www.youtube.com/watch?v=yKL0Pw3Q6mAAnna Lembke explores dopamine detoxing, addiction, and the influence of narratives in managing trauma. SPONSORS:- This episode is sponsored by BetterHelp. Give online therapy a try at https://betterhelp.com/TOE and get on your way to being your best self.TIMESTAMPS:- 00:00:00 Introduction- 00:02:40 Anna Lembke's experience with addiction- 00:10:46 Dopamine-seeking behavior vs coping mechanism- 00:12:35 The paradox of pain relief- 00:24:21 The self-perpetuating cycle of addiction- 00:24:00 Neuroadaptation- 00:29:23 The power of abstinence- 00:34:04 Life as an experiment- 00:37:15 Dopamine reward and misconceptions of the "present moment"- 00:41:06 Freud, Jung, and mindfulness- 00:45:35 East vs West in mental health- 00:51:15 Importance of self-talk and bedside manner- 00:56:00 Attachment styles in trauma (and intergenerational trauma)- 01:01:00 Power of stories and a Higher Power in addiction recovery- 01:07:42 Radical honesty / truth-telling- 01:12:02 The relevance of free will- 01:23:26 Love as a catalyst for tough decisions- 01:31:02 - A digital Sabbath (and Curt's coffee abnegation)- 01:42:12 Methadone for severe opioid use disorder- 01:51:00 The language of addiction, stigmatization, and identity- 01:57:32 Rat Park experiments (society's role in addiction)- 02:08:16 Writing as a therapeutic tool- 02:14:12 The necessity of a Higher PowerTHANK YOU: To Mike Duffy, of https://expandingideas.org and https://dailymystic.org for your insight, help, and recommendations on this channel.- Patreon: https://patreon.com/curtjaimungal (early access to ad-free audio episodes!)- Crypto: https://tinyurl.com/cryptoTOE- PayPal: https://tinyurl.com/paypalTOE- Twitter: https://twitter.com/TOEwithCurt- Discord Invite: https://discord.com/invite/kBcnfNVwqs- iTunes: https://podcasts.apple.com/ca/podcast...- Pandora: https://pdora.co/33b9lfP- Spotify: https://open.spotify.com/show/4gL14b9...- Subreddit r/TheoriesOfEverything: https://reddit.com/r/theoriesofeveryt...- TOE Merch: https://tinyurl.com/TOEmerchLINKS MENTIONED:- Dopamine Nation (Anna Lembke): https://amzn.to/47euRic- Podcast w/ Karl Friston on TOE: https://youtu.be/SWtFU1Lit3M- Podcast w/ Lilian Dindo: https://youtu.be/L_hI7JNsbt0- Discord (new community channel Dopamine Detox): https://discord.com/invite/kBcnfNVwqs- Pure White and Deadly (John Yudkin): https://amzn.to/3snMZHW- Drug Dealer MD (Anna Lembke): https://amzn.to/40G4WOJ

The reason that you're depressed or anxious or inattentive or unable to sleep or just not interested in your life could be because of this high potency substance that you're using or this high potency behavior like pornography and masturbation or online gambling or video game. And if you could just cut that out for a period of time, that would allow those neuroadaptation gremlins to hop off the pain side of the balance and for homeostasis to be restored. Anna Lembke is an award-winning professor at Stanford University who's written extensively on behavioral sciences, addiction, and psychiatry.

She demonstrates how the most minor of activities can lead to ruinous habit formation. And in this podcast, we talk specifically about action steps you can take if you find yourself addicted to pornography, to social media, to masturbation, to drugs, to your phone, to coffee, to virtually anything, because addiction uses the same dopaminergic reward pathways, and so luckily the treatments themselves can be generalized. Questions explored are how do you know you're addicted? Is that different than just being reliant on something like sex or shopping or eating? Is it different than a predilection? We also cover trauma and how that relates to cravings and what you can do about it, of course. Professor Lemke is warm, inviting, and a decidedly open person. Such candidness is rarely seen in any human, let alone a guest on a podcast. I highly recommend picking up her book, Dopamine Nation. Link is in the description, as it'll give you insight into yourself to temper a mild to moderate addiction or dependency, recognize when you're on such a road, and also show you how to help others who

are close to you that are going through something like this. Directly inspired by the book, in the Discord right now, you can go and there's a new channel that's been created called Dopamine Detox, where in November, for 30 days, I'm personally going to abstain from something which i'll announce there and other people will similarly dopamine detox you can choose whatever you like you can announce it and you'll have other people to hold you accountable and a place to go when you feel pulled to what you're supposed to be as chewing so think of something that you would like to rid yourself of for the next 30 days and we we can do so together as a Toge community, making the process much less painful, maybe even enjoyable. I forgot to mention, my name is Kurt Jaimungal. For those of you who are new

to this channel, it's Theories of Everything, where ordinarily it's highly abstract, sometimes philosophical. How do you reconcile general relativity with quantum field theory, for instance? Or what is modal epistemology, and what does that have to do with the morality of artificial intelligence, independent of whether such AI systems can be conscious. Whereas this episode is a decidedly more practical one, much like the episode with Lillian Dindo. Anyhow, enjoy this podcast with Anna Lemke. Professor, I'm so happy to have you on. Thank you. And I've been going through your book, Dopamine Nation, right here. Me and my wife actually have been going through it.

She has some comments. She's like, oh, babe, she writes so well. Please let her know that. Ah, that's nice. Thank you. I spoke with you. I don't know if you recall how we met, but we met with Carl Friston at this event online on Zoom.

Yeah, I remember, of course. Yeah, that was wonderful. You did a great job moderating a diverse panel. Thank you, thank you. So my first question to you is, can you please tell the audience your experience with addiction? Sure. So addiction runs in my family, specifically alcohol use disorder.

But I thought that those genes had skipped me, so to speak, because my early exposure to alcohol was that it wasn't reinforcing at all for me. It just made me sleepy and gave me a headache. So I thought, oh, I guess I don't have whatever that is that people have that makes them vulnerable to addiction. And that was also true for other substances that I had tried. And I just generally felt like I was just too anxious a person to ever want to be sort of out of control, which is how I sort of viewed addiction before I knew anything about it. Little did I know that really addiction is in many ways

the manifestation of an intense desire to be in control. Anyway, interestingly, in my early 40s, I happened upon the whole genre of romance novels. And I have always been a reader and reading has been my great escape from early childhood. And for whatever reason, it was actually the Twilight Saga. For those of you who are not familiar, it's a teenage vampire romance series. So in middle age, I somehow read it because some of my middle-aged friends told me it was really good. And it really transported me. So it just took me outside of myself. In a way, a book hadn't done for a long time. So again, fiction has always done that for me to some degree. But I kind of got really into the whole romance novel genre and started reading every romance novel that I could

find. It started with the vampires and the werewolves and the necromancers, soothsayers, and then it branched out to romance novels more broadly. But interestingly, it wasn't until I got a Kindle that I really became a compulsive reader. What happened as soon as I finished reading one, I could buy another one. I could get them very cheaply on Amazon. I started reading a lot more. I started staying up later and later at night. The other thing was that it was anonymous so that I could read these things that I would generally be embarrassed if somebody found the book lying around. But on my Kindle, nobody knew. And so the combination of those two things, the easy access to what turned out to be an infinite universe of romance novels and the immediate delivery and the anonymity, those things conspired to turn me essentially into a romance novel

addict, so to speak. And again, I don't want to trivialize life-threatening addiction by comparing my experience without some caveats to the problem of life-threatening addiction, which I see and treat in the clinic. But I will say that there were a remarkable number of similarities to what was happening to me in my compulsive reading habit over a couple of years and the same kinds of patterns that I was seeing in my patients. So to make a longer story short, I essentially realized one day that I had a problem and I sort of on myself did the kinds of interventions I asked my patients to do. Namely, I abstained from all romance novels for 30 days and found that I felt a lot better at the end of that time period. I had gotten progressively more depressed and anxious

as people with addiction will do. And when I stopped, I felt better. Then I thought, okay, I can go back to reading in moderation. Then I had what we call the absence violation. So a binge episode where I read all weekend long to the exclusion of doing anything else and then decided, oh, I actually can't moderate this behavior. It's really out of control and compulsive. So then I gave up romance novels essentially forever from that point on. So it's not advisable to test, do I still have this addiction? Let me

dip my toe back in. Do not do that if you have an addiction. No, I wouldn't say that. I would say, in fact, that the majority of our patients who are willing to engage in the abstinence trial, the dopamine fast for 30 days, want to go back to using their drug of choice, but they want to use differently. They want to use less. They want to use in a way that's not as fraught and harmful. And some of them are able to do that with enormous effort and a lot of barriers. Most of them are not able to do that with enormous effort and a lot of barriers. Most of them are not able to do that. But eventually have to test it out a number of times before coming to that conclusion.

Can you clarify what you mean when you say drug of choice? Because I assume that it's not just something physical, it could be an action. And also clarify what you mean by addiction, please. Sure. So addiction is the continued compulsive use of a substance or behavior despite harm to self and or others. When we diagnose addiction clinically, we base it on phenomenology, which is to say very recognizable and repeatable patterns of behaviors that occur across ethnic groups, cultures, time periods that meet this criteria and usually composed of the three Cs, control, compulsion, consequences, that is to say

out of control use, compulsive use, and continued use despite consequences, as well as often tolerance, which is needing more of the drug over time to get the same effect or finding that your drug has stopped working or doing for you what it used to do. And then withdrawal, which is finding that when we try to cut back or quit, that we have a pretty recognizable withdrawal pattern, which makes it difficult. So that's what addiction is. Drug of choice is a really important concept that's understudied in the field of addiction, but it speaks to the enormous inter-individual variability between humans in terms of what is reinforcing for their unique brains. Alcohol, for example, and other drugs, traditional drugs, tend not to be particularly reinforcing for me. So, I just assumed that I

don't have this vulnerability to addiction, but it turned out I just hadn't yet met my drug of choice, which turns out to be in this area of love, attachment, combined with narrative stories and reading. And that turns out to be my drug of choice, what I'm vulnerable to, if other factors conspire to make it very, very accessible, very anonymous, create access to an instantaneous supply, enough novelty. So drug of choice is really important, and it also speaks to a really important aspect of the time that we live in now in that not only do we have more potent forms and more accessibility to traditional drugs like nicotine alcohol cannabis opioids stimulants but we also have a whole universe of drugs that didn't exist before we have uh online pornography we have video games we have online pornography. We have video games. We have online shopping.

We have social media. We have Twitter. We have all these digital drugs, essentially, many of which are about human attachment, which have now exploded the vulnerability to the problem of addiction. Because now, if you haven't found your drug of choice yet, it's coming soon to a website near you. How does one disentangle a dopamine-seeking behavior from a coping mechanism? Addiction is maladaptive coping. So it can start out as adaptive coping. In general, people usually rely on high dopamine rewards. And again, I want to emphasize, it's not that these substances and behaviors themselves contain dopamine. This is a common misconception. It's more that they bind to certain receptors in our brain or stimulate

certain neural circuits in our brain that then as a downstream effect trigger the release of dopamine in our dedicated reward pathway. So I just use it as a shorthand talk about high dopamine substances but the substances themselves don't have dopamine in them. If I were to eat a spoonful of dopamine it would do absolutely nothing because it wouldn't even cross my blood-brain barrier. So typically people know, start out using a substance or a behavior for one of two reasons, either to have fun or to solve a problem. And when it's in the to solve a problem category, then it's essentially a coping mechanism, right? And the reason that people return to using a second, third, or gazillionth time, whatever it may be, is because it works, right? It does what I was looking for. It makes

me, it takes the edge off my anxiety. It helps me go to sleep. It elevates my mood. It helps me pay attention, whatever it is. It alleviates my boredom. It makes me feel less lonely, you name it. But the problem is, you know, that with repeated exposure to the same or similar reinforcing substances, the brain adapts. It starts to downregulate dopamine transmission as well as other neurotransmitters that are there to make us feel good in order to respond to injury or respond to need. And then eventually, we can end up in this kind of chronic dopamine deficit state, which is characterized by anxiety, irritability, insomnia, depression, craving. So the very thing that we were trying to solve turns out to be the thing that we then

exacerbate with continued use. And that's when we've entered addicted brain, when we're harming self and or others. and yet we continue to use that substance even though it's essentially causing harm or continue to do that behavior even though it's causing harm. Is there a reason why we don't hear about serotonin detoxing? We hear about dopamine detoxing? And also in your book, I sense that you're dispelling that dopamine is purely a feel-good hormone. It's more something released in anticipation of a reward. And it's not as if it's pleasurable, if there's a rush associated with it. But it's not the same as gooey feeling great when you hug someone or when you're eating chocolate.

Although maybe dopamine is released there as well. There are other neurotransmitters that come into play. So can you please disentangle dopamine from feeling good, purely feeling good, and then also serotonin from feeling good? And why don't we have a serotonin detox if serotonin also has to do with happiness? Yeah. So let me just parse that a little bit. So different substances and behaviors work through their own unique chemical cascades. work through their own unique chemical cascades. Traditional drugs of abuse are essentially addictive or reinforcing because they mimic a chemical we already make, right? So we already make our own endogenous opioids. The reason people get addicted to opioids that occur in nature is

because they do what our brains already do, but usually in a much more potent way. LSD mimics the serotonin that our brains already makes, right? And typically we get that wonderful oneness or expansive feeling or that feeling of connection to others. With opioids, we get either a euphorin effect or we get a pain-relieving effect or an anxiolytic effect. Alcohol works through our GAaba and opioid systems um and so nicotine works on our nicotinic acetylcholine receptors cannabis works on our endocannabinoid system um love and attachment probably works through both the opioid and serotonin systems right so you've got you know gambling probably works through serotonin and norepinephrine, which is our stimulation system. So these are very complex chemical cascades. consisting broadly of the nucleus accumbens, the ventral tegmental area, which are rich in dopamine

releasing neurons, and connect to the prefrontal cortex, which is our control center of the brain right behind our foreheads. So talking about dopamine is just a simplified way of talking about the ultimate result of all of these reinforcing behaviors. So one way to think about dopamine is that it's the neurotransmitter that says to us, whatever it is you're doing right now that caused me to be released in your brain, this is something that you need to pay a lot of attention to because it's important to your survival, right? Dopamine is the neurotransmitter that says, pay attention to what's going on. It's important. It could be crucial to your survival and you probably will want to do it again and again and again.

Now, what is the role of dopamine and is it really involved in pleasure? And the answer is that with initial exposure, it absolutely is involved with pleasure because we know that different intoxicants and reinforcing substances and behaviors release a lot of dopamine all at once in the reward pathway. And so that dopamine is what makes us feel good and want to do that thing again. However, dopamine is also really important to anticipation of pleasure because when we anticipate doing that thing that released a lot of dopamine, we also get a little hit of dopamine followed by a little mini dopamine deficit state, which then creates the craving to want us to go get the real deal so that we can get more of that dopamine. Furthermore, as people repeatedly expose their brain to reinforcing substances and behaviors,

the brain adapts to those high levels of dopamine, especially if they're exceedingly high, which is what intoxicants will do. And remember, our brain, this reward circuitry evolved in a world of scarcity and ever-present danger, where generally there weren't a lot of rewards around. We had to really work hard to get them. We had to go hungry and walk tens of kilometers and be in without shelter and look for people. And then after working really hard, find a little bit of a reward to give us a little hit of dopamine that basically just put us back to our homeostatic baseline. What we have now is we have at the touch of our fingertips these explosively potent dopamine releasers that give us an explosion of dopamine all at once. And our brains are willing to compensate and compensate by going into this dopamine deficit state.

So that over time, our drug of choice doesn't release much dopamine at all anymore. Instead, what it does is contributes to this compensatory dopamine deficit state as part of the opponent process mechanism. So when we talk about dopamine and whether or not it's about pleasure or whether about reward or whether about anticipation reward, you have to take into account where in the cycle of exposure to that particular stimulus the organism is. The first time the organism is exposed, if it's important for survival or the organism sees it that way, it will lead to a huge release of dopamine. And that is pleasurable.

Otherwise, we wouldn't know to approach it again. Right? So this idea that people say, oh, dopamine doesn't have anything to do with pleasure. It's just about the differential between the baseline and anticipation. It's like, no, there has to be that initial explosion that makes it reinforcing that makes us say, oh, I want to do that again. Okay, great, great. Now here, I know that the people who are listening won't be able to see this, but this is a page from your book. And I'd like you to describe the image and then explain what it's trying to illustrate. Right. So this is a metaphor that I use in the book to try to help people understand what happens

in the brain as we become addicted. What is the result of repeatedly exposing our brains to highly reinforcing dopamine-releasing substances and behaviors? And I use the metaphor of a balance or like a seesaw in a kid's playground representing how we process pleasure and pain. To me, it's very exciting that much of the neuroscience in the last 75 years suggests that pleasure and pain are co-located in the brain, the same parts of the brain that process pleasure also process pain. And you could say they work like opposite sides of a balance. That's obviously highly reductionistic and oversimplified, but as a general metaphor to explain homeostasis and allostasis, I think it works well. So going with that metaphor, when I read a romance novel, because that's a drug of choice

for me, along with chocolate and YouTube videos and other things, I get a release of dopamine in my brain's reward pathway. That's why you didn't watch the YouTube video I sent you. Exactly. Like that's going to trigger you. Really, I was in clinic all day and didn't have time. But yeah, that would be another good reason for me not to watch it. Anyway, that releases dopamine in my brain's reward pathway and my balance tilts to the side of pleasure. But there are certain rules governing this balance.

And the first and most important rule is that the balance wants to remain level, or what neuroscientists call homeostasis. We're always releasing dopamine at a baseline tonic level. Our brains want to go back to that. The question is, how do our brains do that? And the way our brains do that is first by tilting an equal and opposite amount to whatever the initial stimulus is. And I like to imagine that as these neuroadaptation gremlins. They hop on the pain side of the balance to bring me level again, but they like it on the balance. So they stay on until that balance is tilted an equal and opposite amount to the side of pain. That's the come down, the blue Monday, the hangover, that moment of wanting to watch one more YouTube video or read one more chapter in my romance

novel, have one or two or maybe 10 more pieces of chocolate. Now, if I resist that urge, which requires resistance, because remember, the balance wants to return to the level position. So when those gremlins are on the pain side of balance, if I have a box of chocolate, they're very hard not to eat another one. But if I wait enough time, maybe it's seconds, maybe it's minutes, maybe it's hours, maybe it's days, the gremlins hop off and homeostasis is restored. But here's the second rule of the balance. If I continue to expose my brain repeatedly to these high dopamine releasing rewards, that initial deviation to pleasure gets weaker and shorter, but that after response to

pain gets stronger and longer. In other words, the gremlins multiply and they get bigger and stronger. And pretty soon I have enough gremlins on the pain side of my balance to fill this whole room and they're camped out there. And that is allostasis. That's where we change our hedonic or joy set point. Now I need more of my drug in more potent forms, not to feel good, but just to level the balance and feel normal. And when I'm not using, I'm walking around with a balance that's tilted to the side of pain. And I'm experiencing the universal symptoms of withdrawal from any addictive substance or behavior, which are anxiety, irritability, insomnia, dysphoria, and craving. And the reason this is so tricky in clinical care

is because patients will say, well, my cannabis is the only thing that alleviates my anxiety, or alcohol is the only thing that helps my depression. And if you could just fix my depression or fix my anxiety, I wouldn't get addicted, or I wouldn't use this substance in an addictive way. But what they don't see is what was initially a solution to their problem of depression and anxiety has actually become the cause of their depression anxiety. You just performed a restorative linguistic switch here. You flipped their the to an a. So for instance, they said this was the solution. This is the only thing that helps me. In other words, a the. Then you said what was initially a solution so you changed it to it's

not just one it was it could have been many right and so they have a narrow view that's right yeah right i said right this sort of over become coming to overvalue this particular substance or behavior you know kind of narrowing of their focus or interests everything else kind of loses its color. Nothing is interesting anymore. Or things that used to be pleasurable and interesting become less pleasurable. This is what happens in addiction. So it becomes just this one thing can alleviate my anxiety, or this is the only thing that I'm interested in. So for example, in my own life, as I got started to spend more and more time reading romance novels, staying up later and later every night, reading romance novels at family functions,

reading romance novels at work in between patients, the subtle change that occurred that, that I didn't link to the reading romance novels, but which was indeed linked, was that I started to enjoy my work less, started to enjoy my family less. I started to get more depressed. I started to get more anxious. And I started to feel more and more, I just want to be reading romance novels all the time. It's the greatest escape. It's the only place I want to be, the only thing I like doing. Other hobbies fell to the wayside. So this kind of sort of narrowing of focus, the sort of blinders on, this overvaluing this one activity, this having the sense that only this thing is going to give me joy and pleasure,

and not seeing that in fact it is this activity with this, you know, which was initially reinforcing, which is now contributing to my dopamine deficit state or my change to donic set point. And the reason that we know this is because we have neuroimaging studies in humans that show, you know, once people stop using their drug, dopamine, well, when they're using their drug, dopamine levels are actually below the levels of healthy control subjects. So you would think, oh my God, they're ingesting all these drugs. They should have sky high dopamine. No, the opposite is true. They have subnormal levels of dopamine because their brain has down-regulated postsynaptic dopamine receptors, down-regulated dopamine production, all as a way to compensate for this artificial

bathing of their brain in dopamine due to these exogenous sources. So I interrupted you when you were saying that they said this is the only solution and then this is something that initially was a solution but has now become a problem dot dot dot. Right. So patients will come in and say this is, you know, doctor, I need help with my depression or my anxiety or my inattention, whatever it is. And I'll say to them, well, I think there's a distinct possibility because of this process of neuroadaptation and hella stasis that the reason that you're depressed or anxious or inattentive or unable to sleep or just not interested in your life could be because of this high potency substance that you're using or this high potency behavior like pornography and

masturbation or online gambling or video games. And if you could just cut that out for a period of time, that would allow those neuroadaptation gremlins to hop off the pain side of the balance and for homeostasis to be restored. I want to emphasize, we're not asking people to go live in a cave and not have any sensory experiences. What we're asking them to do is identify the problematic substance or behavior in their lives. It's not one that I judge to be problematic. It's one that they've judged to be problematic or a family member has judged to be problematic. And I say, well, let's eliminate that for 30 days. Give time for those neuroadaptation gremlins to hop off the pain side of the balance and for homeostasis to be restored. Recognize that when you first give it up, because you've been accumulating those gremlins on the pain side of the balance,

you're going to feel worse before you feel better. You're going to slam down to the side of pain, but that's withdrawal mediated. And if you can just get through the first 10 to 14 days, those gremlins will get the memo that they should hop off homeostasis or baseline levels of dopamine firing will be restored. And I bet you will feel better without her having to do any other intervention. And they're understandably skeptical because what they say is I've tried every antidepressant, I've tried every psychotherapy, but I can tell you that the only thing that relieves my anxiety, depression, insomnia, and attention is this substance or this behavior. And that's when I validate and I say, I hear you that in that moment it feels better, but all you're really doing is temporarily

restoring a level balance from that pain position and causing those gremlins to multiply further. What you really need to do is give up that substance altogether, let those gremlins hop off and restore homeostasis that way rather than being at war with the gremlins. And what we find is that about 80% of folks who are willing to do that feel enormously improved after 30 days of abstinence without our having done any other intervention. And this is supported by an experiment that was done a long time ago now, probably 20 years ago by Brown and Shuckett, where they took a cohort of adult males who had alcohol use disorder, alcoholism, who also met criteria for major depressive disorder. They put them in a hospital where they had no access to alcohol for one month. They did not give them any treatment for depression at all. Not no psychotherapy, no meds, nothing.

At the end of that time period, 80% of those individuals no longer met criteria for major depressive episode. So simply by stopping drinking, their symptoms of depression resolved. And we see that again and again and again in clinical care. Another phrase you mentioned that's cool is that you said, hey, I'm not asking you to go live in a cave for 30 days. Now, would living in a cave for 30 days be salutary or deleterious? Now, the reason I would think it would be deleterious, and you can tell me if I'm incorrect, is that it's solving something that's quote-unquote extreme, like an addiction, with something else that's extreme. And so then when they come back into the real world, well, they may have solved their problem in a cave, but then they deal with all the back into the real world, well, they may have solved their problem

in a cave, but then they deal with all the triggers of the real world. So some people, when they're going through some, let's say, mental health issues, they feel like, what I need to do, I need to go to Brazil and take ayahuasca. I need to do something extreme. I need to go live in the woods for seven days alone. Is it replacing something that's, let me rephrase that. Is it replacing something intense with something else that's intense? Or not. Maybe it's okay. You could, you could do that. In fact, that's better. Go live in a cave for 30 days. You know, I think there are many paths to the

top of the mountain. You know, it could be that for some individuals being in something like a cave for 30 days might actually be helpful. I think I was using that more metaphorically though to talk a little bit about how the term dopamine fasting is often used here in Silicon Valley, that you have kind of CEO exec types who literally do go into a kind of a cave for a week typically, and then talk about how when they come out after that kind of sensory deprivation, they experience incredible euphoria by very simple things, just the beauty of a flower, you know, a glass of water, whatever,

you know, whatever you have. And I think that that's not what we taught. That's not what we're recommending to our patients because our patients are coming to us, you know, with mental health issues, addiction and other mental health issues. We would never recommend that folks in that fragile and vulnerable state go into a cave. What we might recommend is that they go to a 30-day residential rehabilitation facility where they don't have access to alcohol, but where they're surrounded by people with whom they can make positive therapeutic connections, where they

might get prescribed some medications, where they're in group and individual therapy. But nonetheless, the sort of, you know, Silicon Valley dopamine fast, the point there is, I think, a broader one, which is to say we live in a society today which is very, very noisy. We are constantly overstimulated, constantly being asked to react to enormous quantities of flooding, really, of information. And as a result, our brains are stressed. We are kind of in this constant state of hyperarousal. And because of that, the point is, I think we could all benefit from, in different ways, kind of quieting our lives for a period of time or doing a fast from something that we consume more than we would like. And this is the approach that we take. It's not that,

it's not really realistic, frankly, for most people to even go away to like a retreat or something like that. Most people just have to keep going with their lives. But what they can do is identify one or two substances or behaviors that they use in an out-of-control, compulsive, and harmful way that they would like to manage better in their lives and focus on giving that up for 30 days and then seeing what the impact is. So it's really an experiment. It's like, you know, life is one big experiment. Why not experiment with these everyday behaviors and habits? One of the ways to figure out how a system works is to change a variable in that system and record what happens. And so that's

essentially what we're asking people. Do the experiment. Eliminate alcohol, as long as you're not at risk for life-threatening withdrawal, right? Eliminate cannabis. Eliminate pornography and compulsive masturbation. El video games, eliminate romance novels, see what happens. It can be very instructive. For me, it certainly was. I experienced actual withdrawal where I had intense insomnia in the first 10 to 14 days. That's what we would expect people in those first 10 to 14 days, whether they're giving up sugar or giving up cannabis or giving up romance novels. It's hard. But by weeks three and four, what I experienced and what most of our patients experience is the craving eventually subsides, the mood gets better, the anxiety lessens,

there's a sort of quiet quieting and centering that happens. There's an ability to be more present because we're not constantly looking forward to some future reward, right? Because if you think about it, if you organize your whole day around getting past right now, you and I talking to each other so that I can get to, you know, whatever my Netflix binge or my romance novel or my whatever, you know, then it's harder to be fully present in the moment. But if we give up the kinds of rewards that we're all using to shape our day, we can be fully more present. And people talk about that a lot. I'm able to be more present for my spouse, more present for my

children, more present for other tasks that I have to do. So this is the kind of thing that we ask. It sounds like the first two weeks will be the most difficult. For sure. What should people expect? You mentioned insomnia. And what should people do in order to get over some of the common side effects or detrimental effects or whatever we want to call them? So if one is an AA, I imagine that they can call someone. You have a partner. Now this, many people who are listening, they have people in their lives, but they're alone in this regard. What are they to do? Well, I do think it is very important to stay connected to other people. Ideally, you would

maybe do the exercise together with somebody else. So you're encouraging each other, helping each other remain accountable. This can be in the context of a mutual help group like Alcoholics Anonymous or Cannabis Anonymous or Sexaholics Anonymous, or just with a loving partner or a family member or friend who knows what you're going through, maybe shares that problem, and you can do it together. If you're doing it on your own, you can have a trusted individual. Let people know that you're doing it so that they can help support you in other ways, even if they are not themselves engaging in the dopamine fast activity. I think learning how to just sit with the uncomfortable emotions

how to just sit with the uncomfortable emotions without reaching for our maladaptive uh you know high dopamine reward um and observing how that craving can come and go and and that we can endure it this is sometimes called surfing urge surfing that it can sweep over us like a way but doesn't last forever that can be empowering for people creating alternate activities now one danger with alternate activities is sometimes we replace one reward with another right so instead of reading a romance novel i'm going to have a cookie but the problem with that is cookies are also highly potent and i might end up you know getting addicted to cookies or compulsively eating cookies or just gaining weight, which is not something I would necessarily want to do. So sometimes we recommend actually something called hormesis.

Hormesis is Greek for to set in motion. It's about how we can use painful stimuli to actually upregulate dopamine and other neurotransmitters. to be things like exercising or having a nice cold water bath or intermittent fasting or other things that are actually more challenging than the pain of that craving or withdrawal. And that's another thing that people can try. You mentioned in one of your talks that there's a misconception about the present moment that we think of it as a blissful state, but rather it's characterized by a painful tedium. Can you outline that and help people, help set expectations correctly to guide them through this boredom that they'll experience when they no longer have this addiction or when it's interrupting their thoughts and they have to not follow it?

Yeah. So yeah, let me qualify that quote a little bit. I will say that being present in the moment can be wonderful. But I know that in my youth, I would often hear people like Ram Dass say, be here now, and things like that. And I always tried to do that and found that that was intensely uncomfortable for me because being in my own thoughts and in my own body, I didn't want to be there. That wasn't a particularly delightful place. I have a lot of anxious ruminations and things I worry about and guilt I feel and regrets and on and on. So I kept, I always thought, well, you know, I must not be doing the being in the moment correctly, because if I were, wouldn't I experience some kind of levitating bliss? Because that seems to be what people are promising.

It really took until midlife for me to realize, oh, be here now means being in my mind and in my body, even if it's not a particularly comfortable place. and in my body, even if it's not a particularly comfortable place. And even if I find myself, you know, circling the drain on repetitive ruminative thoughts, if I stay there long enough and, you know, breathe or do whatever other meditation exercises to help with grounding and centering, eventually those kinds of thoughts sort of lose their potency or instead help inform decision-making and moving forward, you know, that voice of our own consciousness telling us things we need to do and listening to it and saying, oh, I should probably do that. If my mind is telling me enough times I should do that, I should say sorry or write a letter, things like that, instead of constantly trying to distract ourselves from ourselves. Razor blades are like diving boards.

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psyche comprising different personalities, some that are nested, some that are intersecting or structures, intra-psychic structures. How do these have bearing on the struggles people will face in addiction? And also, I want to transition to trauma, so you can also talk about that as well. Okay. So are you talking about like the id, the ego, the superego? Yeah, and Jung is quite elaborate. It's much more than that. Jung is more Baroque. There are more complexes and personas and archetypes and a collective. Yeah, I mean, Jung sort of departs from Freud in that Freud believes that...

I mean, Freud's great contribution was that we have this unconscious, right, where we can have these experiences outside of conscious awareness that are very powerful drivers. And that part of the healing process is to become more aware of those unconscious thoughts and feelings and drives. So that was, you know, and that still echoes today in the work that we do. Oftentimes today that presents itself as sort of mindfulness practices. What is mindfulness? It's the ability to observe our thoughts and feelings without judgment. And that would have been something that Freud would very much have championed, right? This idea of, you know, his method for doing it was through psychoanalysis, this sort of uninhibited, sort of unfiltered speech to another rather distant human as a way to get in touch with our unconscious.

That's, of course, Freud's famous psychoanalytic therapy or talk therapy. Jung was a student of Freud, a colleague slash student, but he departed from Freud in that Jung came to believe that there was really what he called the collective unconscious, so that it wasn't that the unconscious just lives within our own mind, it's that really we have a societal or cultural or maybe even metaphysical unconscious that's connecting us all together. And that's where these archetypes live, this idea that there are these sort of universal archetypes that will be the same across cultures and across time periods because they're all

so uniquely human and emerging from this collective human consciousness. So, I mean, I can't say I've really spent a lot of time, like, mapping that onto the addictive process, per se. I mean, I could certainly, you know, sort of think about it now. But it's not something that I've spent a lot of time doing. In some ways, you know, in some ways, I would say my work is sort of nudging people a little bit away from too much introspective time. Uh-huh. behaviors and addictive behaviors is that people would prefer to spend a lot of time introspecting as to why they do a behavior instead of, you know, taking the steps necessary to change the behavior. And in my experience, at least when it comes to addiction, that kind of deep introspection while we're still using our drug of choice is not very fruitful.

It doesn't really get us anywhere. In fact, actions need to come before feelings. So I don't have to understand why I use. I don't have to investigate my trauma. What I need to do is I need to stop using, reset my reward pathways. And then once I've done that and I get my frontal lobe back online talking to my limbic brain or my emotion brain, so I'm not just acting out of my lizard reflexes, then we can begin the work of introspection and looking at, okay, what are some unconscious drives? What are some early trauma

that might have contributed to my turning to substances or needing substances? Then that work is much more fruitful. Yeah, I had a friend who would constantly brood, well, we all have issues, but he had some issues which he would think about over and over and over. I would catch him just sitting in a chair, just unhappy. I would tell him, sometimes it's as simple as if you don't want to eat chocolate, you remove the chocolate from your home. Like you can focus on the actions. And then he would counter with saying,

yeah, but then you're not getting at the root cause. I want to get at the root. I want to get at the root. You fix the root. Don't give me a Western approach. I want to do the Eastern approach of getting straight to the core. Tell me what you think about that general approach. And also, is that even a correct characterization of the East and the West? You can go there if you like. Yeah. I'm not sure it's a correct characterization of East and West because I would say that in Western psychiatry and psychology and mental health,

um, that, that has also been the approach, this kind of deeply retrospective, that is to say, looking in the past and introspective, that is to say, looking inward has been the dominant approach for the last hundred years.

And I think it's important to look at it historically and contextually, you know, When Freud and the many other psychiatrists and psychoanalysts and people thinking about these kinds of things 100 years ago, they were emerging from a kind of Victorian era, stiff upper lip, where people didn't talk about their feelings, where it was highly stigmatized to have mental illness. There were all kinds of somatization, that is physical manifestations of mental health problems, you know, the grand hysterics of the salpatriere. This was how people got emotional needs met. They presented with physical problems because people didn't really have a language or a category for brain diseases that relate to emotion.

And so, of course, you know, the huge contribution of Freud and others was to say, no, no, that's not going to work. We need to really unpack that stuff and look at it and find out what it's related to and what may have contributed to it and how it's contributing to our suffering today. So that was the great unpacking of all of those kinds of repressed feelings. But unfortunately, I think now in the 21st century, we've taken that too far, such that now people are spending enormous amounts of time, in some cases, I would argue, too much time introspecting and retrospecting and trying to look deeply inward to find the cause of their suffering. Would you say they romanticize their suffering? say, giving it too much weight or even going back and reworking quite benign episodes to make them more significant or more traumatic than they really are because we're looking for a causal explanation of our suffering instead of just saying that, wow, all of that could be a contributing factor, but here's what's also a contributing factor, like your

immediate environment, the people that you're with, how you're spending your time, the fact that you're not exercising, that you're not eating right, that you're not getting enough sleep, that you're smoking pot every day, that, you know, you're playing video games 24-7, that you're reading romance novels, you know, whatever you want to do, call it. And that, you know, really maybe that's having a much bigger impact on your mental health than what happened to you when you were eight years old. Furthermore, I think that we have evolved these tropes, especially in Western culture, that really if we're not happy 24-7, there must be something wrong with us or wrong with our lives or wrong with our, you know, relationships.

When in fact, like, life just is hard. And even, you know, the most mentally well person with the most fortunate circumstance is going to experience a great deal of suffering because being human is, you know, a delicate proposition. So I think some of recalibrating around expectations and then also really re-emphasizing behavioral activation and action before spending too much time kind of cogitating on what might be sort of an emotional cause. How important is bedside manner between a therapist and a patient or a doctor and a patient? And what lessons can one learn from that relationship that one can apply to one's own self-talk if one doesn't have a therapist? Okay. Yeah. Interesting question. Well, I mean, I really believe that the primary healing mechanism in psychotherapy or in any doctor-patient relationship is, in fact, the relationship.

impact on their well-being and is much more important in the long run than any pill we could prescribe or the particular type of psychotherapy that we're using. And I'm always reminding my medical students and my residents of this, that it is our healing presence and the gift of listening and being fully present and responsive that is in fact the most important part of our encounters with our patients. And Martin Buber, you know, talks about the I and thou moment. He was a philosopher and a theologian, but I love that. His work is largely unintelligible to me anyway, but the basic concept of I and thou is a very nice concept. It's that two human beings can make an incredibly powerful life-changing connection, even in a fleeting moment of time by really being fully

present for each other. So it is really important. In terms of the other part of your question, which I think was, what was it again? How can you apply the lessons of bedside manner to oneself? If you're lacking in a therapist for whatever reason, you're too uncomfortable or you can't afford it. Yeah. Well, it's a great, it's a great question. I'm not sure it is possible to just do this in isolation. I mean, certainly our self-talk and the way that we, we can be far more empathic with ourselves.

We can be less judgmental. We can sort of interject a kind therapist and imagine what that person would say to us instead of what we're saying to ourselves. So I think that can be helpful. But I do think that there's only so much that we can do on our own. There's only so much that we can do on our own. Again, what is healing about seeing another human being and sharing your inner thoughts is that you're sharing them with another human being. And we are such social beings. We really do need to be in relationship with each other.

And, you know, I think self-help is great. And we can, you know, make a lot of progress by sort of collecting data on what we're doing, really being thoughtful about it, making some small changes, seeing what happens, documenting that. But I do think that in general, doing things in isolation will only get us so far. I imagine that the negative effects in the spectrum of, say, being too judgmental, too tough on oneself, and then leniency, that it's a horseshoe in the sense that you can be too forgiving of yourself, where you allow yourself to be unindustrious and feckless and get away with too much. The proper balance is in the middle, a balance point. Do you find that it's more of the overly

blaming and accusatory type, or that it's more of the overly blaming and accusatory type, or that it's more of the mollycoddling and indulgent type? Yeah, another interesting question. I think, you know, when people are in crisis, it's both of those extremes simultaneously. So there's a lot of self-blame, enormous amount of shame, really paralyzing shame, self-hatred. Self-hatred is a very common modern phenomenon. It's amazing how much people living in the modern world seem to hate themselves. Imposter syndrome, FOMO, all of that. And yet at the same time, people seem to be much more likely when they're in a psychological crisis to lie to themselves, to blame other people, to not really genuinely have difficulty seeing how they've contributed

to a problem, how they've really missed opportunities or failed to be grateful when they could have and should have been grateful. So both of those things are happening simultaneously when people are regressed and in crisis. And it's, you know, probably, you know, this would historically have been filed under primitive defense mechanisms, right? So all of those kinds of regressed, primitive, maladaptive things that we do as we realize we're, you know, feel threatened as an organism and feel that we have to defend ourselves against a hostile universe. Did you find that when you're writing this book, Dopamine Nation, or any of your books, is it therapeutic? It's not therapeutic in the sense that I'm solving problems that I didn't know the answer to.

in the sense that I'm solving problems that I didn't know the answer to. It is therapeutic in the sense that it's the only solitary creative work that I do. My professional life is immersed in service to patients and to students and mentees. And everything I do is people intensive and collaborative. I'm with people all the time. I have to be fully present with those individuals as both part of my moral. That sounds like it takes so much of a toll. It takes an enormous amount of energy, but I love it. So it's rewarding for me. But to be fully present for other humans is exhausting. So the writing of the books is like a day a week I give to myself where I don't talk to anybody after sending my kids off to school. At least that's when I'm really writing. I'm not doing that work now because I don't have time.

But when I do do that work, and so it's really a gift to myself. It's kind of letting myself play hooky and play in the playground. And so it's very satisfying in that regard. David Foster Wallace said that good writing is ego death. Ah. Do you resonate with that yeah you know um i do in the sense that if you think if you if when you're writing you get too caught up in how people will respond to it or whether it's any good you don't get very far you have to really be coming from a very different place um for me uh you know it comes from a place of like um trying to help people you know hoping my writing will help other people that's that's part of it uh and also from kind of again a gift

to myself as a kind of creative occupational therapy rather than uh sort of a psychological psychoanalytic understanding of myself. I mean, hopefully, I've worked some things out before I try to put them on paper. What are attachment styles and trauma? What are they? Yeah. Well, I'm not an expert in attachment styles. There are lots of good books out there on this, but obviously, our earliest human attachments with our caregivers goes a long way to shaping how we go through the world.

And people have analyzed the different attachment styles that are out that, you know, whatever environment we grow up in, if we're going to survive, we have to figure out how to survive in that environment. And what can be an effective coping strategy in a dysfunctional environment doesn't then necessarily serve us well once we leave that environment. And so I think that's kind of, you know of one conceptualization of trauma that if you're raised in a very dysfunctional environment, you're naturally going to develop coping styles that will help you survive that environment, but in the long run, will not necessarily serve you well in your life. And so then there's an incredible reworking that

has to happen. So what is intergenerational trauma and then what role does that have to play in addiction or addictive personalities or compulsions or habits, habit formation? Right. So intergenerational trauma has to do with the ways in which these maladaptive coping strategies or family system styles that, you know, that evolve in a given family will get passed on to grandchildren and great-grandchildren because we don't just pass on our genes. We also pass on everything to do with how we navigate the world. Plus, there's a whole area. Right, the memes, if you want to call it that. Plus, there's a whole area of epigenetics

that looks at how, in fact, those behaviors can actually become part of our DNA and get literally passed on in our genes. And that's a very interesting work and makes sense to me that, you know, through our repetitive behaviors, you're going to express some proteins and not others. And the expression of those proteins will then affect, you know, future generations. When we spoke last time, we talked off air about the power of stories and the power of a higher power. And we wanted to talk about that this time. So please, what are stories? How are they relevant here? And how is a higher power relevant to any of this? We're all storytelling machines. We have large parts of our prefrontal cortex that are dedicated toward narrative. And narrative is essential to

humans as a way to organize past experience. But our autobiographical narratives are also roadmaps for our own future. So they become not just a way to organize the past, but also a way to know how to make decisions going forward. And one of the things that, you know, I think happens in good psychotherapy is that the therapist and the patient together explore autobiographical narratives and try to figure out, in my opinion, you know, one that hews as closely as possible to reality or what really happened. Because I think when we're telling true stories, we have access to better information to make decisions going forward. But when we're telling stories that really aren't true about ourselves, which by the way, we're very prone to do. True as in factual, sorry?

True as in factual, true as in factual. Yeah. Yeah. When we're not telling truthful and factual stories, then we don't have access to good information to make choices going forward. So stories are really, really important. They're sort of our, you talk about memes. I mean, we pass these things down through generations through the stories we tell, you know, and stories are also a fundamental way to experience lived time, that was Foucault, but also to understand cause and effect. I know no better way in theuko but also to understand cause and effect i know no better way in the human realm to understand true cause and effect than through storytelling um so and in terms of higher power i mean this this is a really fascinating area to me but

it essentially has to do with like locus of control. And what I've seen again and again in recovery from severe addiction is that, especially people with the severest forms of addiction, that eventually the only thing that really gets them into recovery is to give that locus of control over to a power greater than themselves. Now, that doesn't need to be like a deity necessarily. It could be the mystery of the universe, or it could be, you know, my AA fellowship, or it could be, you know, the power of love. But basically, it's the acknowledgement, at least, you know, with severe addiction that when I'm in charge and only relying on myself and my own decision-making, things go awry. try to work to contain or manage or control my life, the worse things actually get. So there's this amazing pivot that occurs when people give up that sense of control to a higher power and let instead life unfold and try to commune with that higher power either through meditation or prayer or going to meetings or fellowship or what have you. That people then begin to be able to access a wisdom and a strength that otherwise they don't have access to.

And then begin to make much better decisions in their lives. So is this higher power just anything that's outside of you that has more control over you than you do of yourself. Because if that's the case, I could imagine that everyone believes in a higher power. Well, if you're a Marxist, you believe it's the corporations. If you're a capitalist, maybe it's the government. If you're someone who doesn't like your job, maybe it's your boss. That person has so much more power than me. And I imagine that that's not terribly helpful in the way that when people say, believe in a higher power or recognize that there's a higher power and that will help you through your addiction. I imagine that that's not what's meant.

So please delineate what's meant by higher power. Yeah, great, great, great point. So to clarify further, the higher power is something higher than any human agency. The higher power is something higher than any human agency. So not just higher than my human agency, but higher than any human being could possibly. So there's no other human being or human element that could solve this problem, right? So it's something meta, something outside of human agency and human understanding it's it's much much higher than than that yeah i don't know if there are studies on this but is it more powerful if it's considered to be divine a divine higher power or is it more powerful if it's a secular higher power like it

must be the objective universe that has no emotion yeah Yeah. Unfortunately, I feel like our language in this space is so limited because I don't think it needs to be necessarily a divine human power. And yet, I'm not sure calling it a secular human power really fully captures it. I think, I believe very strongly that it doesn't even really need necessarily to be defined. And this is in some ways the genius of AA. It's a higher power according to your understanding. So, I mean, I don't think you need to define it. For some people, it's very important to define it. It's important for them to know, is this God? If so, whose God is it? What religion is this going to be associated with? But for many people, that's

not important at all and proves not to be the critical element. It's really more a profound stance of humility and willingness and acknowledging that I don't know who's in control, but I know it's not me and I know it's not you. Humility is a great word because it's also related to being humiliated. And it sounds to me like in one of your other talks when referencing telling the truth, something I was thinking, I don't know if this is the case, I'm going to tell you what my thoughts are, I want to hear what your thoughts are, is that there are truths, so we can just begin to never lie and tell the truth. But then there are also lies that we have told in the past, and do we come forward with those? Well, that's much more tricky because there's a mountain of them. So one option is you confess all those lies to

this higher power. But you have to believe in quote-unquote in this higher power. Otherwise, it's not humiliating to confess. And there's something about walking through the fire that is where the redemptive qualities are. That if there's no consequence to it, then your confession was for naught. It was as if you just told a cup. And maybe the cup to some people is divine. And in that case, that's fine, but that's rare. Yeah, I think you're right. I mean, when we think about a higher power, however we define it,

there has to be a sense of shock and awe, and maybe even a little bit of terror before that the word power with higher power has any meaning, right? Actually, Kierkegaard wrote about this concept of, Kierkegaard's the coiner of the leap of faith, and he wrote about this concept of infinite resignation, that before you can even have this leap of faith, there has to be this kind of infinite resignation of recognizing, in a way, the profoundest humility of our own efforts to really get to that place that a higher power can transport us. And while we're on the topic of speaking the truth or telling the truth, can you outline why that's important? And not just neurobiologically, like not just, okay, the prefrontal cortex is strengthened, but somehow psychologically as well. Yeah.

So this idea of like radical honesty, it comes from my work with patients over the years, finding that those who are able to get into recovery from the severest addictions and stay in recovery are the ones that have learned that they can't lie about anything. lie about their use. They can't lie about why they're late for a meeting, what they had for breakfast, where they're going to be Saturday night. It's those trivial lies that they have to be the most careful about because that will lead them back into the bigger lies about using. And to me, that's fascinating. I mean, what is it about embracing this concept of radical honesty and never lying that helps people with addiction. I think it works on a bunch of different levels. One of the levels that it works on is just their own insight and awareness of what they're actually doing. So part of what happens when we lie, and the average adult tells one to two lies per day, is that we're not just lying to

other people, we're largely also lying to ourselves. And to talk about Freud's unconscious, we're allowing certain themes and things that we do and say and think to remain in those dark recesses of our minds. Whereas if we're articulating something, there's something very, very powerful of turning our inner life into words that we share with another human. It really makes it real in a way that it's not otherwise, and it hugely enhances our awareness of it. So that's one of the big things. The other thing is that telling the truth profoundly enhances intimacy. We're deathly afraid of people knowing our faults and weaknesses, our deep desires, our shameful desires, whatever it is. We're afraid that if we tell people, they'll run away from us. But in fact, the opposite happens. If we really share our shame, people come to us.

They want to be closer to us. It enhances trust. So it's a wonderful way of augmenting intimacy. And very often, that kind of deep intimacy or connection to other human beings is the best antidote to addiction. I just saw a patient today. He has a sex addiction addiction and he was experiencing intense cravings. He and his wife had a bunch of things to do around the house and he was kind of dreading doing those things. And, you know, he's struggling in his addiction and out of the blue

came this craving to act out that basically he was planning that after she went to bed, he would look at pornography, which is, you know, of a relapse. And then it occurred to him, well, you know what, I'm just going to let her know what's going on for me. And he said, I just want to let you know, I'm having a lot of cravings right now, wanting to act out and I'm formulating a plan. And she responded by saying, thank you for sharing that with me. Do you want to talk about it? Is there anything that I can do to help? That's sweet. Well, even better, even better after they talked about it,

and she went to bed, he had no cravings. So his cravings went away. And really what's so key there is that really what was the craving in search of? It was in search of some intimate human connection at a point when he was feeling low. So instead of escaping to his addiction to try to fill that feeling, he actually faced it head on, expressed his inner life and his shameful cravings to his wife and then got intimacy from that. And that's just a wonderful example of how being truthful in the moment can really bring people together. And then the craving goes, which is really awesome. So if I was to recapitulate, please let me know if this is correct or incorrect.

When you lie, you feel as if you're manipulating and you're getting away with something, like you've achieved something, something positive. Otherwise, you wouldn't have lied. But what's actually happening is that you poison yourself. You've corrupted your heart, and your heart is a large aspect of you. And further, and maybe you don't know this, but my background is in math and filmmaking. There's a screenwriting adage that says, the more specific the pain, the more applicable it is or the more relatable it is. And further, the more general you try to be, the less relatable it is paradoxically. In other words, you think that you're going to repulse someone by revealing your innermost specific, painful, personal thoughts, but what actually happens is that you endear people to you.

And then further, what you've articulated is that you also get endeared to other people. So I don't know if I interpreted what you said correctly in my own inference or my own translation, but tell me what you think. phrasing, but I mean, I think you're, you know, similar themes. I think, you know, what I touched on is just how telling the truth makes us more aware and gives us more insight into what we're actually doing. Because when we don't tell the truth, we are not aware of these behaviors. They remain in our unconscious, and then we continue to lie to ourselves so that that's one of the primary ways that this radical truth-telling can be helpful is that it increases our knowledge base right then it increases our perception it increases the the information that we're taking in about the world which then enhances our models right so if we're going to use active inference language, we improve our perception, we improve our models, and then we have better models going forward to interpret the world.

Does free will have any relevance here? Like it's important to believe in free will, or it's actually better if you do not, if you say, no, this is not in my control? I don't know. I don't know the answer to that. That's a great question. I do think often about free will, and I haven't even concluded myself what I've decided about it one way or another. But the other thing is that, well, let me just say I would like to believe in free will. I think that's a better universe where we have some free will. free will. I think that's a better universe where we have some free will. And I do think that that degree of randomness that's built into the universe is that opportunity for free will.

But the other thing is just that telling the truth also enhances intimacy. It allows us to draw near to other people, which then serves as an antidote to addictive behaviors. So insight and intimacy are two of the ways. There are other ways that radical truth-telling is helpful, but those are two ways. What is this hard-earned wisdom that people have when they go through an addiction and then they come out of it, or trauma and then come out of it? Or maybe my language of quote-unquote coming out of it is not something that's helpful, but please translate into however it should be. Well, I mean, I think any type of profound suffering that we come through the other side, you know, hopefully makes us stronger and wiser. That is an idea that's been around forever.

There's this idea from Japan, I'm not going to remember the name of it, but this idea that if you break a bowl and you put it back together and you glaze it, it's stronger than it was in its original form. So I think that's true. That's been sort of a truism in all cultures in some shape or form. It's not always true. Sometimes a broken bowl can't be put back together and that's a shame. But when it can, then the idea is that it's, you know, we're stronger for it. Yeah. And does it also make you more resilient? I think so. Yeah, absolutely. Yeah. And are there some interventions that are better for eliciting this wisdom slash resilience?

So for instance, a pharmacological one is not as good or a talk therapy one in combination with medication is the best. I don't know if there's studies on this. Yeah, it sort of, it depends on the disorder and it depends on the person and it depends on the circumstance. You know, sometimes for some people, medication is the best answer. For others, it's, you know, medication is the best answer. For others, it's different. It's like a social intervention. Sometimes it's a combination of the two.

It sort of depends on what disorder you're treating. I would hate to generalize across the board for every single disorder. I do think in general we're too quick to prescribe medications in many instances, and then we over-medicate, and there's a big problem with polypharmacy. Our healthcare system- Polypharmacy. Yeah, just kind of using a lot of drugs all at once, not really knowing what's working. Certainly in the United States, our healthcare system is designed for prescribing pills and doing procedures.

We're not very well set up for kind of slow medicine, doing psychotherapies, social interventions. And that's unfortunate because for a lot of chronic illnesses, chronic mental illnesses, chronic pain illnesses, those kinds of slow interventions probably work better in the long run. But you don't want to throw the baby out with the bathwater. For patients of yours that can lucid dream, have you found it to be helpful? Like you say, okay, if you're in your dream, ask this question to this character. You know, I don't really know much about that. I've certainly heard about it, but I can't say I know really even what that

is. Okay. We've talked about individual action plenty on this podcast, and we've talked about patient to individual action. So what about family to individual? So if you're a part of a family and you want to help an individual or a friend group and you want to help an individual. And then also what about society? Yeah. So, I mean, in terms of, are you asking specifically if you have a friend or family member who are struggling with addiction? Yeah. There are two questions in there. So what do you do if you have a friend or a family member that's suffering in this way? How do you treat them? How do you view them in your head as well in order to have a positive outcome? And then later we'll get to the society question. I'll just re-ask that afterward. Yeah. Well, I think that the medical

model here is very useful, the disease model of addiction, which basically argues that there are predisposing innate genetic factors for developing addiction. And then plus we live in an addictogenic world where we're surrounded by highly reinforcing drugs and behaviors at the touch of our fingertips, making us all more vulnerable to this problem. And that once we expose our brains repeatedly over time to this highly reinforcing substance or behavior, we essentially change our brains. You know, as I've talked about, we can go into this dopamine deficit state. And then we do lose some degree of our own personal agency. We're slaves to this hijacked brain or where our brain mistakes this rewarding substance or behavior as something necessary for survival. We start to commit all of our available resources to getting the drug, hiding the drug, withdrawing from the drug, and doing it all over again.

And the reason that I think that's a good model is because it's supported by the evidence, but it's also a model that helps elicit compassion and the realization that our loved one is not choosing the drug over us, but rather our loved one has lost the ability to choose, that they really are caught in the vortex of addiction. Because otherwise what happens is that there's a lot of shame and blame and people feeling that their loved one cares more about the drug than they do about them. I just saw a couple this afternoon in their 70s and he can't stop drinking. And she says he won't stop drinking, but he literally on some level can't stop drinking. So it's painful to see that. I mean, it doesn't mean that the family member can't

feel anger because that's appropriate. But again, recognizing that it is a brain disease and this person has lost their personal agency to the disease. So when it comes to then interacting with family members, I think it's good to choose a time in which we're not dysregulated and they're not intoxicated or withdrawing and then bring up the topic and just express it as something that you're bringing up because you care about them and you want what's best for them and it's painful to watch them do X, Y, or Z, or that they may not realize that X, Y, or Z substance or behavior is causing these kinds of problems. So to act as a kind of

calm and compassionate mirror to reflect back to them the impact of their substance use or their addictive behaviors on their lives and on our lives. Because people don't see that or they don't let themselves be aware of it. Now what about, okay we're going to get to society in just a moment, what about now flipping it from individual to family or individual to friends? So you're that individual or the person who's listening is that individual who feels as if you're that individual or the person who's listening is that individual who feels as if they're addicted to something and they know it and they know that they harm the people around them. But at the same time, they want some sympathy from the people around them. Like, look, please help me. You need to understand where I'm coming from.

So what do they do other than send them this podcast? What do they do? What do they tell the friends and the family members? Oh, what does a person with addiction do? Yeah. Well, I mean, I think there can be words and actions. And usually if there aren't actions tied to the words, people aren't going to put much weight into the words. So if a person with addiction really wants to get better, then they can say that to others. I really want to change. Here are the steps I'm going to take to try to change. And here's what you can do to support me. But you can't just say, oh, I have addiction. And so it's a disease and I have no agency. So you should feel badly for me and let me do what I want. That's not what we're talking about.

We're talking about a disease. It's both a disease process and one for which that individual can and needs to take responsibility for reaching out for help. So maybe they can't stop on their own, but they can choose to turn to others and open themselves up to getting help. And if they're unwilling to do that as well, then I think the loved one has the right to say as well, then, you know, I think the loved one has the right to say, well, I love you, but I can't live with you anymore, right? I can't, I mean, I feel for you and all that, but if you're not going to take these steps to make some changes, then there are going to be real life consequences, including I may leave or I may stop supporting you or you may have to leave or whatever it is.

One of the things that I have learned after two decades of treating people with addiction is that many people with severe addiction will not find the motivation to change unless there are real life consequences for them. They lose their housing, they lose a spouse, they lose their rights to be with their children, they lose their job, they dui so a consequences you know and and family members can empathically and in a frame of loving a family member uh deliver consequences so i'm you know sorry you can't live here anymore we love you we care about you but we don't want to enable this addiction you can't live here anymore and i think sometimes that's the right thing to do yeah so in other words they're saying the words i love you but i have to kick you out though what they mean is i love you and because i love you i have

to kick you out there you go it's not even a butt right that's right that we have this view of love as simply tenderness and clemency that's's right. Yeah, yeah, good. So the reason I had asked about the society question is I wanted to go over to the audience questions. And that's a nice segue. Someone from the audience had asked, why treat the individual in a sick society? Shouldn't you treat the society? What is it? Like our society is sick. It's an abnormal society. I'm sure you've heard these claims. So why are we treating the person? Well, yeah, I mean, it's essentially the claim I'm making in Dopamine Nation, right? The big idea there is that the location of the disease process is not in our individual brains. It's in the world that we live in now, in which we are surrounded by

highly reinforcing substances and behaviors at the tip of our fingers, and we're told that we should pursue consumption. That's kind of our raison d'etre. And so I absolutely agree with that, that in order for us to be healthy, we have to change the modern ecosystem. And the way that we need to change is we need to limit access to highly reinforcing drugs and behaviors and we have to develop a new kind of social etiquette around eschewing or avoiding uh you know intoxicants except in extreme moderation and actually doing things that are challenging or difficult or even painful as a way to kind of reset our reward pathways. And we have to do it with a sense of meaning and purpose derived not just from the fact that we will individually feel better if we do that, but also we will save our planet.

I mean, our consumptive behaviors are not only self-destructive, they're also highly destructive to the environment and to the planet that we live on, the way that we're absolutely depleting our forest fuel sources, fisheries, you name it, because we eat too much and we smoke too much and we drink too much and we buy too many cars and all of it. Have you read Pure, White, and Deadly by John Yudkin? No.

So it's a book from the 70s, I believe. And he makes the case that the problem in our society, or one of the largest problems, is overconsumption of refined sugars, which I think you can generalize to empty carbs. And so in the self-development world, there's something called keystone habits, and working out is one of them. So if you do this, the rest of your life benefits, and your other positive habits will come more easily. Is it the case? Have you seen that it's the case where if someone is over consuming on carbs, then it affects the rest of their life in negative ways with respect to what you treat them for clinically? Oh, sure.

what you treat them for clinically? Oh, sure. So we see actually quite a lot of food addiction in our clinic, independent of obesity, which is sort of interesting. Some people who binge on foods, and I would say basically we all have disordered eating in the modern age. Our food supply is so plentiful and so drugified with the addition of fat, salt, sugar, and other flavorants that we're all prone to overeat and then trying to find out. I was talking to my wife the other day. I said, so what's there to eat? She's like, there's so much food. She lists all the food. And I'm like, yeah, but what else is there? She's like, there's soup and there's salad in the fridge. I'm like, you don't tell someone who's hungry that there's soup and salad.

Right, and so you have appetitive things where you've lost desire for certain foods unless they're just the food you want in that moment. But many people are struggling in other ways where they can't stop eating these highly processed, highly caloric foods for the first time in human history, there are more people on the planet with obesity than who are underweight or malnourished. For the first time in human history, people are getting surgeries to reroute their intestines so that they can

manage their overconsumption. So we've clearly reached a tipping point with our food supply. And we see more and more people who are outright addicted to food even separate from being obese people who compulsively over consume food until they're essentially passed out just the way that people drink alcohol in that manner so um and you know foods foods are real addiction so yeah it it's it shows up in all kinds of ways just the way that other addictions can make people depressed and anxious and inattentive and unable to sleep and not able to be present and narrowing of focus and all those things. We see that with food addiction, too. The next question, which comes from the audience, is what should I do to parent my young child?

And also, is there a difference between young boys and young girls in this regard? boys and young girls in this regard? Yeah, so I do think there are differences between boys and girls in the sense that the kinds of, let's say, intoxicants or drugs that girls will gravitate to, like social media, are just slightly different than boys on average. These are gross generalizations. Boys, it's more likely to be pornography and video games as well as substances. likely to be pornography and video games as well as substances. Although interestingly, over time, we've seen more and more girls use things like alcohol, such that now there are as many women in the United States struggling with alcohol use disorder, alcohol addiction as men, which is very different from past generations where the ratio was more like two to one and then hundreds of years ago it was more like five to one men to women so women are you know drug use is much more socially normalized now among women and so more and more women are developing drug addictions but you know

speaking of parenting young children i mean i just think all of the things that we know already the kind of common sense things to have healthy attachments, to spend time together as families. But in particular with the devices, I think kids under the age of 11 or 12 should really not have their own devices that give them unfettered access to the internet. Yeah. So I do think that we can't underestimate the power of these digital drugs. Digital content is highly reinforcing and quantity and frequency matters. So to sort of say, well, my kid likes video games, they can play video games in every free moment. I think that we can't do that as parents. That would be essentially like giving our kids a pack of cigarettes and saying, go at it. I think we have to recognize the addictive potential, which doesn't mean no video games, but it does mean really, you know, or social media or whatever, even pornography, because kids are using it. So I think to have open, honest discussions and really think about limiting use. I talk with families a lot about, you know, having behavioral contracts, making sure kids do their homework and their family chores. Behavioral contract.

Yeah, so kind of where you have, you know, people have to do certain things to earn the time on video games and social media or time on their devices. And then have that time be limited where they have to give it back. Interesting. For adults, could that be implemented to yourself or in combination with a partner? Yeah, absolutely. Absolutely. And then I really recommend that families do like a digital Sabbath where they take one day a week or even just a half day a week where everybody leaves their devices at home, all the devices, and they do something together with no devices. I think it's super important for parents to model what they want their kids to do.

You know, I have a lot of parents who are on their devices constantly and then complain that their kids are on their devices constantly. It's like, well, if you don't change your behavior, you're not going to change theirs. Our actions as parents are much, much louder than words. So if our kids see us constantly on our devices, they're going to think, oh, that's how, that's how, you know, that's how you do it. So I think really important to have times when we're not on devices, like dinner times or other family occasions. Professor, I find whenever I leave my phone at home, I love it. Like I'm with my wife and I'm much more present.

But invariably, right before I'm about to leave the house, even though I have all the evidence of all the other times where I've enjoyed myself, I say, yeah, but there's going to be an emergency where I'll need to call someone. So let me, I'll come up with some excuse to bring it. Yeah, I know. People feel really naked without their phones. It's true. But the truth of the matter is, if there really were an emergency, what would your phone allow you to do to manage that? Someone's going to call 911 or they're going to help out.

If you're not physically there, what can you do anyway? I never really carry a smartphone around except when I'm traveling and I need to do Uber or something like that. And I tell you, I think my quality of life is really enhanced by that. Professor, I'll confess something right now. really enhanced by that. Professor, I'll confess something right now. You have me at a time where because of your book, your book has made me get off of coffee. And right now I'm six days off coffee. So I'm loopy and it's your fault. I'm inarticulate. Oh, and by the way, you mentioned that it's much better to do a detox, a-unquote dopamine detox a 30-day one with

other people and so inspired by you when this launches right now in the discord for this channel which is like a chat room yeah will be a dedicated channel in the chat room for a 30-day detox where you if you want to give up something i'll give up something we'll all state what it is if you want to make it public and then we can keep each other accountable for the next 30 days. This should release in early November, late October. Yeah. That's great. I love it. Yeah. That's great that you're doing that. I'm wondering, are you willing to share how much coffee you were drinking? Two and a half cups. Okay. And what made you decide to give it up?

Well, I drink coffee four times a week. Okay. And I take three days off because I want to make sure that I'm not adapted to it. And it still gives the alert effects that I want. But then I thought, you know, many people say coffee increases anxiety. And I have anxiety. Okay. And also increases sleeplessness.

And I have insomnia, like horrible insomnia. Okay, yeah. Horrible, horrible insomnia. Okay, yeah. Horrible, horrible insomnia. I'm sorry. Oh my gosh. I'm sorry. Yeah, that's hard. So I thought, why not eliminate caffeine?

Sorry, coffee. Why not eliminate coffee? Go back to drinking black tea. Okay. So retain the caffeine, but it's much less in black tea, especially if you just have one. Okay. Is it harder than you thought it would be?

No. Today's the worst day. Okay. Day three. I feel so horrible, but it's great because I have you to speak to. Oh, there you go. Okay. Good. Good. Well, good. Well, I mean, yeah. Yeah, right. Well, good for you for trying it because it doesn't even sound like it was particularly problematic, except that you're wondering, and that's a good thing to wonder about, whether you could improve anxiety and insomnia by eliminating it for longer. And I think that's a worthy experiment because for some people, caffeine really can increase anxiety and insomnia. So I think it is a really interesting and good experiment. So good for you. And make sure that you stay the full 30 days. Cause if you just do

it for, you know, two weeks, you won't, you'll get all the hard part without the benefit. You really have to do it long enough to kind of your brain kind of gets a message. Oh, well, this coffee's really not coming. So I guess I'm going to make some changes here. So I'll be curious, I'll be curious to know how it goes. Specifically. What motivated me was your distinction between mild and moderate addictions. And I don't think I have an addiction to coffee how it goes. Specifically what motivated me was your distinction between mild and moderate addictions. And I don't think I have an addiction to coffee, but I think it was approaching a mild addiction. So it goes mild, moderate to what? Extreme?

Severe. Severe. To severe. Okay. Yeah. And I'm not even sure you would make the cutoff for a coffee addiction. I think for you, you're even just maybe a little, you know, maybe an entrenched habit or slightly compulsive thing. But even in those situations, you know, kind of taking a break can be instructive.

Many people wanted to know about how is it that they can self-assess if they're on the route to a mild addiction, if not mild to moderate. route to a mild addiction, if not mild to moderate? And I know that psychiatrists and health professionals will always say, go seek a health professional, go seek your family doctor. But in the absence of that, is there some rudimentary set of five questions someone can ask? Oh, sure. I mean, I would say open up the Diagnostic and Statistical Manual of Mental Disorders. There are 11 criteria. You can go through those criteria. If you meet two or more of those criteria, then you would meet criteria for a mild use disorder. So that's what I would do. In an effort to keep this podcast a complete resource, I'm going to list out the 11 questions from the DSM-5 about addiction. Count how many

times you say yes. Number one, do you sometimes have difficulty controlling how much you use your drug or how long you use it? Also recall that you can substitute the word behavior for drug. Number two, have you made any unsuccessful attempts to cut down your usage? Number three, do you sometimes spend a significant amount of time using or recovering from your usage of drugs or engaging in that behavior? Number four, has your drug had any negative effects at home, at school, at work? Number five, has it negatively impacted your social life? Number six, do you continue to use despite negative consequences? Number seven, have you put off things or neglected to do things because of your drug use

or your behaviors? Number eight, do you have strong cravings? Number nine, has your tolerance increased? Are you able to use more than you did before? Number 10, have you experienced withdrawal symptoms the next day? Number 11, has it led to any dangerous situations? Okay, now the criteria is that if you've answered yes to two or three of these, you have a mild substance abuse. If you've answered yes to four or five of them, you have a moderate substance abuse. Six or more is severe. Keep in mind, no single test is completely accurate

and you should always consult your physician when making a decision about your health. Another question that comes from the audience is, is it better to be addicted to something that's a positive habit like working out? So when I use the word addiction, I'm really talking about psychopathology. That means you've crossed the line from it being adaptive

or it being a hobby or it being a habit into it being a mental illness, which means it has to be compulsive, it has to be out of control, and it has to cause harm to self and or others. Short of that, I don't really call it an addiction. But it is true that some people can get addicted to even behaviors that we typically think of as healthy, like exercising, or in my case, reading or maybe playing chess or other things that we think of as, well, that can't be an addiction because you're playing chess and smart people play chess or whatever it is. But the truth is that we're all wired slightly differently. We all have a different drug of choice.

We all have a different drug of choice. And so it is possible, although it's much harder and not as common, but it is possible to get addicted to exercise. So how does that look when people are addicted to exercise? That means they're compulsively engaging in exercise despite repetitive injuries, despite seeing a doctor who says you've got to stop doing that, despite family members saying it's really adversely impacting our family life that you have to spend X hours every day doing your sport. Yeah, so my mother-in-law, anytime I'll give her any supplements like melatonin, she'll say, is that addictive? Am I going to get addicted? What she means is, am I going to have a tendency to that? Am I going to now rely on that? So what is the word that she should be using? It's not addiction.

It is what? Well, I actually think the way she's using it is exactly correct. And good for her for asking it, because there are a lot of pills that get passed out by doctors and otherwise that actually are dangerous and addictive and people taking them don't know. I can't tell you how many people we see who were started on a benzodiazepine like Xanax or Valium or Ativan or Klonopin who then cannot get off and come and say, my doctor never told me this was addictive. So what do we mean by saying something is addictive? We mean that the average person with enough exposure to that substance or behavior will find it difficult to stop even when they want to. And with intoxicants, that's generally true, right? So like opioids prescribed for pain by a doctor are still addictive because the average

person with enough time on an opioid will have trouble getting off of that opioid. And yeah, it might just be dependence, physical dependence, but in the olden days, physical dependence and addiction were synonymous. Now we kind of separate those two, allowing for, for example, doctors prescribing things to patients that are dependence forming but i mean i think you could debate whether or not there really is a difference between those things especially from a neurobiological perspective um so good for your mother-in-law for asking you that and not just indiscriminately taking pills that somebody gives to her somebody her son-in-law her son-in-law and trust and let me say you know and then and that gets back to this original question about like, you know, a healthy activity

like exercise. So generally exercise is not addictive, but can you get addicted to it? You sure can, right? Also because we've drugified exercise. We have these machines that make it easier to do more repetitive motions more intensely. We have all these ways to count it. We now have leaderboards and social media that's ranking us. Yeah, we're gamifying it. So we've taken something that before it was nearly impossible to get addicted to it, and now it's a lot easier. This one said, since 2008 and haven't been better. Good job. Got my child back and so on. All positive things have happened for me. I hate that I have to take it each morning, but the benefit in my life has far outweighed the bad. Just curious her thoughts. Yeah, you know, I ultimately think that we need

to be practical about these things. And methadone maintenance for severe opioid use disorder is evidence-based treatment. It's one severe opioid use disorder is evidence-based treatment. It's one of the best and most evidence-based treatments that we have for any addictive disorder. Sounds like it's really working for you. I would urge you to stay on it and consider it the equivalent of insulin for diabetes, that essentially this is a medicine that you will probably need for the rest of your life as long as it continues to work well for you. And in my book, Dopamine Nation, I do talk about opioid agonist treatments like methadone and buprenorphine. And I explain from a neurochemical point of view, you know, why they work and why they're important. Okay. The last question now, and then you and I have

got to get some rest, just relax. Yes. So we've talked about phone addiction. What you can do is you can just have an abstinence day and put your phone away, maybe one day a week or so. Okay. What are the three strategies that are most effective for dealing with addictive behaviors of porn, alcohol, and other drugs such as smoking? And also, are strategies different than tactics? Well, I would say, you know, this is what I cover in my book.

It's encompassed by the dopamine acronym. The interventions, whether it's a drug use, alcohol use disorder, or a behavioral addiction like sex, compulsive masturbation, gambling, shopping, video games, are pretty much the same. That first, you want to collect the data, what you're doing, how much and how often. You want to, that's D for data. This is the dopamine acronym. O is for objectives.

Why are you doing it? What are you hoping to get out of it? Are you really getting out of it what you're hoping to get out of it, or is there a gap between those things? P stands for problems associated with use. Write down all the things that are not working about using that substance. The A is for abstinence. Do four weeks of not using it.

You'll feel worse before you feel better. You'll collect data on yourself. You'll be able to tell what the true impact of that behavior is on your life. Really hard to know while you're in your consumption, but if you take a break from it, you'll get more perspective, get better and accurate information. The M stands for mindfulness. This is what we talked about, learning to just surf the urge or sit with that emotion, watch it come and go, tolerate uncomfortable emotions without reaching for our drug of choice. The I stands for insight.

That's practicing radical honesty and the ways in which we become more aware of our behaviors and actions by telling the truth about them to ourselves and others. The N stands for next steps. If we make it through the 30 days and we feel better, and we can decide, do I want to continue abstinence from this substance or behavior, from this particular video game, or from pornography and masturbation, or from online shopping sites, or from cannabis, or do I want to go back to using but use less, use differently? If you decide to go back to using, but use less, use differently? If you decide to go back to using, make a really detailed plan for what that is going to look like,

how much and how often. So this is the question that comes up, well, what do we do after the dopamine fast? I'm not going to be able to, you know, I'm still going to live in the world. I don't want to abstain forever. So then, okay, well, what is your use going to look like? What are your red flags? How are you going to hold yourself accountable? And then the E for dopamine stands for experiment. And that's where we go back into the world and give it a try again for another 30 days. Okay, my goal was moderation. You know, in my case, I tried to go back to reading romance novels and binged all weekend

long and showed up at work bleary-eyed and said, that's not going to work for me. So then committed to a long-term abstinence. But for other people, they may be successful moderating or they may be successful for a while and then slip it back into more compulsive overuse or they may be successful but decide it's not worth it because it's exhausting. Abstinence is easier. So it's just one big experiment. is easier. So it's just one big experiment. The links to all books referenced and all articles referenced and everything will be in the description. The current book is Dopamine Nation. The previous book is Drug Dealer MD. It's about the overprescribing epidemic. Yeah. Are you working on anything new? Actually, I'm working on a Dopamine Nation workbook. So this is an interactive workbook that people can make their way through to do that kind of dopamine acronym that we talked

about. You know, data, objectives, problems, abstinence trial, otherwise known as the dopamine fast, mindfulness, insight, next steps and experiment. And so it's kind of walks through people with all kinds of interactive exercises. There are a lot of fake dopamine nation workbooks on the market, but this is the one that will be really by me and will be the companion for dopamine nation, the book and coming out in May, 2024. There were some extra questions for Anna conducted on a separate day, which you're about to see. So professor, how important is forgiveness and apologizing both for you to yourself, for you to others, and maybe even family and friends to you if you're the addicted one, you in quotations?

Yeah, well, I mean, I think, I mean, what does an apology consist? An apology starts with acknowledging that in some ways we've done wrong or we've harmed somebody else through our actions or words. So I think that's very important to acknowledge that when we've harmed others, and it's somewhat instinctive, I think, for humans to want to both see themselves in the best light and also be their own worst enemy. It's sort of a polarizing reflex, meaning that we can be very hard on ourselves at the same time that we can be far too easy on ourselves and generally want to rationalize behavior that's harmful toward others without recognizing our own contribution. And I think it's really important for understanding life to also be honest with ourselves and recognize and become aware of the ways that we have harmed other people. It's very hard to look at that, but it's important.

After we've done that, the next step is to let people know that we are aware that we've harmed them and that we feel contrition or sadness, regret for that behavior, combined with the desire to want to make amends. And what does that mean? Amends is a forward looking. So, you know, apologizing and regret, that's looking toward the past. And amends is looking toward the future and saying, well, I'm not going to do this behavior again. So, for example, in my own life with one of my kids, I started reading her journal, which I rationalized to myself was appropriate because she had a health condition and I was concerned she wasn't sharing with me the things I needed to know in order to help her with her health. But really, that was a transgression of her privacy. It was a wrong thing. I knew it was a

wrong thing when I was doing it, but I rationalized it nonetheless. And it took me a long time to get around to telling her that I had done that. And part of my reluctance was that I knew once I told her and apologized that I wouldn't be able to keep doing it, right? So that's the whole amends part. The apology really has to come with the intention of changing the behavior or at least trying to change the behavior. And so, you know, eventually I did apologize and she was incredibly gracious about it and said, that's terrible that you did that. And it did, you you know impact her trust of me um but she was also even in that moment able to forgive me which speaks to her very wonderful nature as well as the good foundation of our relationship that even though i had significantly breached our you know that that trust i could apologize make amends and we can rebuild. And I really think

that's the foundation of apology. It's respecting ourselves and the other person and the relationship enough to want to continue to make it better. And that's the way that we make relationships better because we're always going to make mistakes. We're all very flawed. We're always going to make mistakes. We're all very flawed. Is it important for you to be forgiven? So you're apologizing, but sometimes the person won't say, well, I forgive you. Maybe they'll say, yeah, you should be apologizing. You deserve the snubbing that I'm about to give to you or whatever it may be.

Yeah, right. Well, that's, of course, the great fear behind admitting that we've done wrong and apologizing is that the person won't accept our apology or that they'll be so horrified by what we've done that they won't want to have anything to do with us going forward. That is the great fear. But I really do think that nine times out of ten, we think that the person is going to run screaming from us when in fact the opposite happens they're in fact drawn closer because honesty is a great gift again if an apology comes with desire to change the behavior uh that's an acknowledgement of wanting to invest in that person in the relationship so i think generally um apologizing you know a good good faith apology is a way to strengthen relationships. It doesn't typically lead to a worsening of that relationship. Now, for an addict, is it important for them to

conceptualize themselves as an addict? Or should I not even say what I just said, which is as an addict, like am I contributing to some stereotype by saying so, or a stigma? Yeah, it's such a great question, because the language around addiction is really evolving. And there's a whole group, especially inside medicine, that, you know, feels like we should try to de-stigmatize the language of addiction. For example, not use the term addict, but use the term something, what we call patient-centered language of addiction. For example, not use the term addict, but use the term something, what we call patient-centered language, a person with addiction, a person with the disease of addiction, a person with an alcohol use disorder, rather than saying that's an alcoholic

or that's an addict. And there are other terms, you know, sort of talking about urine toxicology screens is either clean or dirty. You know, that's people, people feel stigmatized, right? Yeah. But on the flip side, a lot of people in the community of people with addiction who are trying to get into recovery refer to themselves as addicts, alcoholics. So on, so in a funny kind of way, it's somewhat invalidating to say, well, we shouldn't use that language when the very people struggling with these disorders will identify themselves in that way. I mean, who are we in the medical community to say what language should be used by the very people who embody those disorders? So I don't know. I'm personally somewhat conflicted about it.

And so getting to the underlying point of your question, it took me a while to get there, but I eventually did. What is the nature or the role of identity in addiction and recovery? role of identity in addiction and recovery. And, you know, identity is really important and sort of coming to know yourself and also redefine yourself in the world is an important part of recovery. And acknowledging and identifying that you do, in fact, have an addictive disorder and that you may need to turn to others for help with that is an important part in that identity transition for people. So the people who you mentioned that refer to themselves as addicts, do they do so because of just the history? That's just what they've learned? Or do they find it helpful? Because it implies that their addiction is more powerful than them and it's useful for them to conceptualize it like that because then they know I need to seek help? You know, it's probably not possible to generalize.

You know, some people who refer to themselves as addicts, it might be helpful to do that. Others might use that as a kind of embodiment of the justification of why they can just keep using and will never be able to stop. So it's, you know, it's, it's probably cuts both ways. Yeah. That's an interesting point. Tony Robbins mentioned something like that. Tony Robbins, a motivational speaker. He said, look, if you don't smoke, if someone offers you a cigarette, you don't say I'm not into smoking. You say, I'm not a smoker. Like you actually have that as part of your identity that you're not a smoker. And he said, it's important. He said,

the way that you frame your identity can help you get over or move toward what you want. Yeah, right. Yeah, you're absolutely right. And it does, again, speak to the ways in which adopting certain identities can be helpful or harmful. You know, in the Alcoholics Anonymous and 12-Step community, they feel that self-identifying as an addict, including calling yourself, for example, a smoker or calling yourself an alcoholic or an addict, is fundamental to the process of recovery because you are acknowledging that unlike normal people or normies, you can't use that substance in moderation. You can't use it recreationally the way that other people might. Once you start using, you will continue to use, it will lead to all kinds of significant problems, and your life will become unmanageable. So in that, you know, contrary to Tony Robbins, which I'm not saying he's not wrong, I'm just saying I think for different personalities and

different temperaments, you know, sort of adopting agency through certain identities, depending upon the person saying I'm not a smoker will be the very thing that helps them move away from smoking. For other people saying, you know what, I am a smoker in the sense that I'm not somebody who can just have a cigarette now. And then if I have one cigarette, I'm going to be smoking a pack a day within two weeks. So anyway, these are just interesting things to think about. I understand. You smiled when I said Tony Robbins.

So you're familiar with Tony Robbins? Yeah, of course. Yeah. Can you please tell me more? Because I wasn't aware that many academic psychologists know about him or his practices, and I've always wondered, what are their views on it? Well, I don't feel I know enough to honestly go into it in a public... I mean, I've heard of him. I know many, many people have benefited from his work

and have quit smoking as a result. I think that's fabulous. Great, great. Professor, what are the Rat Park experiments? And what do they tell us about addiction or society's impact on addiction? He essentially challenged the prevailing paradigm in studying addiction in the laboratory, which was to put a rat in a very small cage with a lever, which if pressed would deliver intravenous cocaine or what have you to the rat and then to a lever for cocaine in a small cage with nothing else to do, that rat will essentially press the lever till exhaustion or death. So that became a kind of working animal model for studying addiction. Bruce Alexander came along and said, hey, you know, if you put pretty much any human being in a room with nothing to do but press a lever for cocaine, that's what they're going to do. And that's not, you know, that's

not adequately simulating, you know, what really happens in life. And his hypothesis was that if you put a rat in a very, very large cage with a lever that they can press for cocaine. But a lot of other things that they might do, sawdust, piles of sawdust they can explore, running wheels, a maze, other rats. Right. It's very likely that they're not going to necessarily press that lever or press it quite as often. And so that was the rat park experiment. He and his colleagues built a giant maze. They put these rats in and according to their results, rats were less inclined to press a lever for cocaine when they had other things to do. And since that time, the whole rat park experiment has really become somewhat iconic and really a metaphor more than anything

else for the need for a healthy environment and healthy alternative sources of dopamine if we want to intervene in the serious public health problem of addiction. That battling addiction, whether you're dealing with rats or human beings, is not simply going to be a matter of, for example, limiting access to drugs or treating drug addiction. It's got to be looking more holistically at the environment and identifying what makes for a healthy community, what makes for a healthy environment, and then promoting those things as well. And the human experiments that maybe were inspired directly by Rat Park, but maybe not, I don't know, were things like the ice studies in Iceland, where they opened up a bunch of youth gymnasiums. They created a youth curfew so teenagers couldn't go out past a certain time of day. They promoted all kinds of social goods and social networking, and they saw a reduction in teen drug and alcohol use in their communities. use in their communities. So again, it's just this sort of idea that the holistic social environment really matters. One of the claims that I've made is that the problem with the world that

we live in today is not just that we have a rat park, but we have actually a rat amusement park. So we've taken even healthy kinds of activities and we've drugified them. We've made them more reinforcing. We've made them more accessible, more potent, more novel. So it's such that now we can get addicted to and or binge on just about anything such that this idea of rat park, you know, has to take into the account the fact that science, technology, and just our own propensity for extremism in everything that we do has turned what was previously healthy stuff into potentially addictive stuff, like social media, right, has taken human connection and human relationships and distilled it down into its most addictive essentials,

whether it's, you know, through dating apps or Instagram or Discord on a video game or what have you. So I think that's really important to acknowledge. Also, footnote to that, which I find fascinating, is that running wheels, you know, a rat on a running wheel, scientists used to think that a running wheel was a neutral or inner measurement of physical activity in rats. But then they began to notice that certain rats would preferentially run on the running wheel to using cocaine, but not in moderation. They would actually run on that running wheel till complete exhaustion. In other words, it looks like some rats get addicted to running wheels to the point where they run themselves to death. So I just think that's an interesting and fascinating metaphor

too for human life today, where even things like exercise have been made more technological, more addictive with all the machines that we have and addition of social media and leaderboards and rankings and all of these ways that we can see what other people are doing and how far they went. And so it's just, it's just interesting. I imagine you would say that the addiction to exercise would be one of the more positive addictions, though. Or is that not the case? Well, when I use the word addiction, I'm talking about psychopathology defined as the

continued compulsive use of a substance or behavior despite harm to self or others. I certainly have made and will continue to make the strong argument in favor of exercise as a healthy way to get dopamine indirectly by paying for it up front. But anything that gets dopamine, even if it's a healthy way to get dopamine, if overdone, can lead to addiction. So when I talk about exercise addiction, I'm not talking about healthy, adaptive amounts of exercise. I'm talking about people who are exercising to the point where they're getting injured. They're not stopping when they're injured. It's interfering with their family life, with their job.

They've really genuinely become compulsive about it. And oftentimes exercise addiction, although rare, is occurring with more frequency. Again, as we've kind of professionalized and technologized, if I could say that, making up a word, and technologized, if I could say that, making up a word, all of these exercise pursuits, people are now constantly counting themselves. And we know that that kind of quantification makes people more compulsive about their behaviors. Exercise addiction is often also linked to restrictive eating behaviors, et cetera. That's super interesting because there's someone named David Goggins, who is a motivation, not a motivational speaker. Let me think. What is he? He's a motivational guy. I wouldn't say motivational speaker, but some guy who many people find helpful because he's

this epitome of someone who can push through extreme suffering for some goal. So he'll run even if his legs start to bleed and he'll just keep going on this race over and over because he said, I'm going to run two marathons today. And so I'm going to do that no matter what. And I used to look at that as well and be like, wow, that's something to be emulated or something to have as a value, even if you don't achieve it. But now I'm wondering, is that just a sign of addiction itself? Because he repeats this in every other activity that he does. So he started yoga, and then he just does yoga for three hours or four hours. Right. Well, I think that, you know, many people find inspiration in people who, in other people who do things that are really difficult.

And I think that is admirable. People who challenge themselves, who take on painful or difficult activities, that is inspiring and those people can function as heroes. But without commenting on any individual person, because I'm not familiar with the specific, I'm familiar with Goggins, but not with his specific activities. I do think we need to draw into, and people, of course, are starting. So a very advanced athlete who pushes themselves very far, that might be healthy for that person. Whereas for a person who never gets up off the couch, for them to do that might be healthy for that person. Whereas for a person who never gets up off the couch, for them to do that would be harmful. So it sort of depends where you're starting. You know, again, again, I want to emphasize exercise is one of the most potent

antidepressants, anxiolytics, even anti-addiction activities out there. But it can be taken to an extreme. And this kind of, you know, continuing to do it beyond what is healthful, I think is something that we need to pay attention to. Professor, given that you could have gone into any field of medicine, maybe any field in general, why did you choose addiction as a subfield? And if you didn't start in addiction, then why did you choose that? I'm always interested in, look, there's a plethora that you could have chosen from. Yeah, right. Yeah.

But you walked through one or two doors out of 300. Right. So why? Well, I mean, this is kind of cliched, but addiction found me not the other way around. I did choose psychiatry because I was interested more in quality of life than quantity of life. And I wanted to have enduring relationships through time with my patients, which psychiatry, thank goodness, still affords us in modern medicine. But I was actively avoiding patients with addiction early in my psychiatric career, primarily because I had learned very little in medical school or residency in how to treat them. And I also, like most of my colleagues, conceptualized addiction as

a social problem, a willpower problem, not something within the purview of medicine, not something for doctors to treat. And this was 25 years ago or so. But what happened was I discovered that if you have a patient with bipolar disorder who's also addicted to alcohol or drugs, you can prescribe all the mood stabilizers in the world and you can be the best psychotherapist and you can talk about every conversation they ever had with their mother. And if you don't also address the addictive behaviors, they are not going to get better. And that was really my realization. I realized that I was actually not functioning as a very good psychiatrist because I was ignoring the addictive problems that my patients actively had. And they weren't bringing it up because I wasn't asking because it's a stigmatizing behavior associated with a lot of shame.

Right, right, right. it up because I wasn't asking because it's a stigmatizing behavior associated with a lot of shame. People aren't going to disclose it unless you as a skilled practitioner give them the opportunity to do that. So that was essentially the shift. Have you found that writing about your addiction or writing about trauma? So I know those are maybe separate questions, but maybe there's something common underlying. Have you found that that's helpful? And under what circumstances? Like what questions should someone be asking themselves when they write? So when you say write, do you mean sort of like keeping your own journal or writing? Or do you mean writing for an audience? No, I just mean for yourself. It doesn't have to be a journal. It could just be two years after the event, if it's a traumatizing event, or maybe while you're attempting to help yourself out of an addiction, to just write about it. Because I heard that writing as a whole is salvific when it comes to psychological conditions, like getting

over psychological conditions, that is. But I don't know what sort of writing is salvific, because there are various forms. Right. So, I mean, again, I would say there's a lot of inter-individual variability. You know, what might work for one person wouldn't necessarily work for another. But in general, we organize our thoughts and feelings through language. We understand our experiences through language. And so by putting our experiences and our thoughts and emotions into coherent language, especially if we're then using that to communicate with another human being, we ourselves can become aware of cause and effect in a way that's hard if we're not using language to organize the sort of cacophony that's happening in our own minds. I will say, though, that I think

for people with severe addiction trying to get in recovery, you know, isolation is such a big part of the disease. And I would think that writing in isolation would, in general, not be as effective as writing or communicating in a way that is shared. This is, of course, why 12 Steps and other mutual help groups are so useful. They, in fact, provide a structure to organize experience. And so people are creating a narrative within that useful structure rather than just kind of some sort of, some sort of a stream of consciousness, which I'm not sure is necessarily all that helpful.

Speaking of writing, when your book, Dopamine Nation, became a bestseller, and it was winning, still is winning awards, at the time when the flurry of events were occurring, what was going through your mind? How are you feeling? At the time, when the flurry of events were occurring, what was going through your mind? How were you feeling? You know, for me, the process of writing a book is very rewarding in the sense that almost all the work that I do is collaborative and is service-oriented and is interacting with others. So for me, the book writing was a creative thing that I could do in quiet moments by myself. So the process itself I found enjoyable, and I really didn't give much thought to what would happen

after it was published. Of course, whenever you write a book, you want people to read it. You think you have the audience in mind. You're thinking of people reading it. You're wondering what their reaction will be. But I have to say, for me, that was not, for the books that I've written, the sort of primary motive. It was really very process-oriented. You know, with Dopamine Nation and also my prior book, Drug Dealer MD, it was a surprise that people, a lot of people read the book and seemed to find it useful. humbling like wow I'm really lucky that I had the opportunity to express these ideas and that in expressing these ideas people are receiving these ideas and and finding them helpful and

expressing gratitude I mean that's I feel very fortunate that I've had the opera that opportunity so out of all your achievements in clinical practice and in literature, which holds a special place in your heart? I mean, really, the thing that's closest to my heart in my professional life is taking care of patients. And to this day, I still love taking care of patients. It's the most gratifying thing that I do. People are fascinating. People's heroism in the face of very difficult odds is inspiring. And even to this day, I have a lot of joy in seeing patients

and taking care of patients and in teaching too, because in a way that's sort of an extension of that same sort of thing. You know, sort of having young people who are interested in doing this work and helping them, you know, realize their dream. That's also very rewarding. Was there a patient who reshaped your understanding of addiction most? And obviously you can speak in generalities here. It was never going to be one person. I think it was, you know, just the river of human lives that I've experienced from my office here over 25 years that's had a huge impact on me and the way that I see the world. And

every single one, I would say, shaped me in some way. Earlier when we spoke about a higher power, you mentioned that it needs to transcend you as a person. And to the physicist or to the materialists, the law of nature or the laws of nature would do that. But then they would be hard-pressed to find some solace in it if it's just the reductive laws of quantum field theory, for instance. So what else is there to this notion of a higher power that is necessary for it to be nutritious? Well, I wouldn't presume to tell anybody else what their higher power is. I think the key piece of this shift, this kind of spiritual shift and the importance of spirituality for many people in recovery is really the acknowledgement of the locus of control

not being within them, but being in a, and not being actually in another person either, but being somewhere outside of them or satisfied in themselves. And I think for some people, just that is enough, this shift of locus of control. For other people, there's a much stronger need to more specifically define what is the source of control? How personal is it in my life? You know, how much is my life part of a plan that this external force has imagined for me? I think people are very different in their need for that. But almost always that shift, and I will say that's not for everybody.

There are some people for whom kind of believing that they are in control and that they can exert their control to overcome their addiction is the key piece for them. So, again, it's not a universal. There are many paths to the top of this mountain. reversal. There are many paths to the top of this mountain. But for many people that I've seen, because really it's this wanting to exert their control on the world and people around them that gets them into their addiction, it's the letting go then that allows them to find recovery. Did you happen to find a common characteristic between people who feel like they need or actually find it salutary to retain the control and to emphasize that I have control over this addiction versus those who find it more nourishing to let go?

Like, is there something that unifies those people? Yeah, I have given some thought to this. I think there's no research that I know of looking at this, and I don't know, I'm not sure what I think about this, because I don't see that many people who get into recovery by taking more control. Typically, by taking more control. Typically, what I see is that it's the failure of taking that control and this kind of letting go and admitting that they're out of control. That is really the key turning point for many people. However, they define that, which doesn't need to be in a religious or theistic or even spiritual frame. But typically, that's what I see. But I could see that, for example, somebody who really felt that their

life was very much out of control and someone who had a certain degree of learned helplessness, that for that person, kind of feeling that they have some control could be the path to recovery. A topic that's important nowadays, maybe in all of human history, is free will, the argument of whether we have it or not. And I understand that there's some evidence that suggests that the belief in free will leads to an improved life satisfaction. But it sounds like here, there may be a divide. Like you're not supposed to.

No, no, I don't think there's a divide. I think you can, um, you know, surrender to a higher power and also believe that you have agency and responsibility. It's just, what is it that we have agency over, you know, and, and is it possible to have both agency? Is it possible to have agency in a world in which there's also this concept of a power greater than ourselves that has, you know, is determining what happens next to some extent in our lives? I think those things are totally compatible and can coexist. What would you like to be remembered for? Oh, gosh. I haven't even given this any thought. I don't know. I guess I wouldn't be remembered as

a good mother, a good wife, a good doctor, and a good teacher. Okay. Thank you. You're welcome. Okay. Now, me and you got to get some sleep. Yes. Or at welcome. Okay. Now me and you got to get some sleep. Yes. Or at least some rest. Thank you so much, Kurt. I'm so glad you got questions from the audience. That's great. So we can answer what people are really interested in.

Take good care, Kurt. Get some sleep. I will. I will. You're going to sleep well tonight, I think. Yeah, I think so as well. Okay. Take care. Take care. Bye-bye. Bye-bye. Once more, in case you missed it, in an effort to keep this podcast a complete resource,

I'm going to list out the 11 questions from the DSM-5 about addiction. Count how many times you say yes. Number one, do you sometimes have difficulty controlling how much you use your drug or how long you use it? Also recall that you can substitute the word behavior for drug. Number two, have you made any unsuccessful attempts to cut down your usage? Number three, do you sometimes spend a significant amount of time using or recovering from your usage of drugs or engaging in that behavior? Number four, has your drug had any negative effects at home, at school,

at work? Number five, has it negatively impacted your social life? Number six, do you continue to use despite negative consequences? Number seven, have you put off things or neglected to do things because of your drug use or your behaviors? Number eight, do you have strong cravings? Number nine, has your tolerance increased? Are you able to use more than you did before? Number 10, have you experienced withdrawal symptoms the next day? Number 11, has it led to any dangerous situations? Okay, now the criteria is that if you've answered yes

to two or three of these, you have a mild substance abuse. If you've answered yes to four or five of them, you have a moderate substance abuse. Six or more is severe. Keep in mind, no single test is completely accurate and you should always consult your physician when making a decision about your health. We've been having issues monetizing the channel with sponsorship, so if you'd like to contribute to the continuation of Theories of Everything,

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